Gender and Drug Usage
By Sonja Woolley
Author’s Note:
Many studies only track participants within the gender binary, mentioning “male” and “female” drug users especially in the context of sex-based hormones like estrogen or testosterone. Gender and sex are two different entities and conflating them as the same ignores the diverse spectrum of gender identity. Working with this data inherently means that much of the chapter only focuses on cisgender male/female drug usage, which I recognize is not fully inclusive. I’ve attempted to mitigate this exclusion by recognizing a wide range of studies, but there is definitely more work to be done for broad inclusion in this area of scientific and sociological research.
Gender plays a large role in the ways in which the drug industry impacts individuals who work within the system and those who are impacted by machismo culture surrounding the drug trade. But this is not where the differences end. From start to finish – cultivation and production to trafficking, policing, and right to the hands of users themselves – gender differences are inherent. Research indicates that the gender of a drug user impacts why they start using drugs, how long they continue, methods for using, and how they are treated for addiction. This distinction in drug user experience based on gender comes down to both biological and sociological differences. Biologically, the gender of a drug user impacts susceptibility to usage, potential recovery, and risk of relapse based on factors such as hormone production and body size and composition. Sociologically, gender impacts many different factors related to responsibilities, reasons for drug usage, success of treatment, and societal stigma.
On the first look, there seems to be a clear difference between the experiences of male and female drug users. Research demonstrates that in almost all cases, men are more likely to use illicit drugs and suffer from a substance use disorder (SUD). [1] Men start using at a younger age than women and tend to use higher doses of substances more frequently. [2] This leads to higher rates of emergency room visits for drug usage, and more deaths as a result of overdose in comparison to women. Many societal factors contribute to this discrepancy. Research from the National Institute on Drug Abuse (NIDA) suggests that more men use drugs earlier not because they are more susceptible to drug use, but because they have more opportunities through peer groups and are socialized into more risk-taking behavior than women. [3] Despite these differences, when controlled for societal effects, women are just as likely as men to develop a substance use disorder. [4]
Sociological Effects
People are socialized based on gender and these expectations contribute to different substance use experiences for men and women, particularly manifesting in differing preferred substances by gender and for what reasons they are used. The Rolling Stones have a song that represents a helpful anecdote based on this fact. In 1966, the band released a song entitled “Mother’s Little Helper” which discusses middle-class drug usage and gender dynamics by satirizing the plight of housewives. The lyrics reference “a little yellow pill,” which describes a prescription benzodiazepine like Valium or Meprobamate, commonly prescribed in the 1960s to treat anxiety and insomnia. [5] The song comments on the societal pressures and expectations placed on wives and mothers.
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“Mother needs something today to calm her down
And though she's not really ill, there's a little yellow pill
She goes running for the shelter of her mother's little helper
And it helps her on her way, gets her through her busy day
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They just don't appreciate that you get tired
They're so hard to satisfy, you can tranquilize your mind
So go running for the shelter of a mother's little helper
"Life's just much too hard today, " I hear every mother say
The pursuit of happiness just seems a bore
And if you take more of those, you will get an overdose
No more running for the shelter of a mother's little helper.”
The Rolling Stones bring up an interesting comparison to be found when looking at motivators for drug usage. Women report using methamphetamine because they believe it will increase energy to deal with factors like work, child care, and family responsibilities. Women use to handle other societal pressure, too – significantly more women than men report using methamphetamine to lose weight. [6] In contrast, men report using methamphetamine at higher rates than women for sexual enhancement and the ability to work more. [7] These reported reasons demonstrate how drug usage is socialized differently by
gender, and illustrates the societal factors that impact illicit drug usage.
Physically or emotionally traumatized people are at the highest risk for developing a substance use disorder. Because trauma often coincides with conditions like depression, anxiety, or PTSD, it is not a surprise that the majority of individuals who develop SUDs are also suffering from mental health disorders. [8] This is impacted by gender because the incidence of psychiatric conditions that correlate with drug use are more predominant in women, transgender people, and gender-nonconforming people. [9]
Source: 2019 National Survey on Drug Use and Health (samsa.gov)
Biological Effects
Estradiol (estrogen) chemical compound
Societal factors impact the likelihood that some people start using illicit drugs, but research has shown that biological factors can lead to drug usage experiences that differ based on sex-based hormone production. Studies
conducted on both human and animal participants has shown that the hormone estrogen impacts the
effects of stimulants like cocaine and methamphetamine. Estrogen production is one of many
factors that can lead to an increased vulnerability of the reinforcement mechanism of these
stimulant drugs. This hormone-based sensitivity contributes to the fact that women
relapse at a higher rate than men after going through rehabilitation. [10] Other
studies on estrogen and drug usage show that female cocaine users are less likely
than male users to suffer from blood flow abnormalities in the brain. This means that
estrogen can protect users from some of the detrimental effects of cocaine that
lead to deficits in learning and concentration. However, the protection that estrogen provides is associated with longer periods of cocaine use and using higher amounts, increasing the potential of long-term neurological damage. These studies demonstrate that a hormone-related mechanism in the brain can impact sensitivity to stimulants, creating implications for how easily a user can become addicted based on their hormone levels. [11] However, though these differences are increasingly recognized by researchers in the field, there is still a lack of gender-based study to mitigate these differences when it comes to treatment and rehabilitation.
Much of the existing research on gender and drug usage notes that there is a lack of understanding on why addiction differs by gender. There are very few studies that focus on the experiences of female drug users specifically. For many years, research on addiction focused only on male users, creating an exclusionary bias that persists today. [12] The very hormones that have been shown to impact sensitivity to drugs were a primary driver behind researchers’ exclusion of women from clinical trials – some scientists were concerned that hormones or menstrual cycles would cause problems with continuity and validity of study outcomes. [13] This exclusion has led to a lack of understanding on how addiction affects people based on their hormonal levels, which not only impacts women but also transgender and gender non-conforming people. This makes it difficult to develop effective prevention and treatment strategies for those struggling with addiction.
Transgender and Non-Binary Community
Note: I use the term non-binary to describe a variety of identities that fall outside of the gender binary – genderqueer, gender-nonconforming, gender-fluid, two-spirit, pangender, agender, and more. Though I recognize that each individual may identify under a different term, I have chosen to use “non-binary” as an umbrella term for brevity.
Arguably the most excluded group in studies on addiction and rehabilitation are queer and transgender drug users. In general, the LGBTQ+ community faces disproportionately high rates of substance use – it is estimated that 20-30% of gay and transgender people use illicit drugs, compared to about 9% of the general population. [14]
However, because addiction studies have historically preferred cisgender men, there is a lack of data on the rates of SUD in the queer community. Community-based studies denote a perception of widespread drug use – the 2015 National Survey on Drug Use and Health found that LGBQ+ adults are more than twice as likely to use illicit drugs and/or suffer from SUD than their heterosexual counterparts. [15] This study, however, only focused on sexual orientation rather than gender identity. Of the addiction and drug use literature that does include the queer community, trans and non-binary identity is rarely studied on its own or completely left out. This fact is significant considering that there is compelling research that suggests a highly elevated rate of illicit drug use among these communities. A 2017 study found that almost 25% of transgender young adults reported past month illicit drug use. This one in four number is nearly five times higher than the 5% of cisgender participants who reported similar use. [16] Surveys of the LGBTQ+ community indicate an internal perception of drug use – nearly 50% of respondents report they know a few people struggling with drug abuse, and another 27% reported that they know many people experiencing addiction. [17] A study that focused on substance use in middle and high school found that transgender students were about 2.5 times more likely to use stimulants like methamphetamines and cocaine. [18]
These discrepancies between drug use in cisgender/ heterosexual groups versus gender diverse/queer groups are credited to the comparatively high rates of mental health struggles in the LGBTQ+ community – something researchers attribute to minority stress. Minority stress describes “the negative effects associated with the adverse social conditions experienced by individuals of a marginalized social group.” [19] This chronic stress can be triggered by everyday experiences and general social
prejudices as well as institutional laws and policies that discriminate against the queer community. Again, large-scale studies of mental health fail to include the full range of LGBTQIA+ identities, but there is strong evidence that members of these communities are at higher risk of suffering from a mental illness, especially anxiety or depression. Transgender and non-binary individuals in particular feel this burden – according to a 2020 study by The Trevor Project, for transgender and non-binary youth, more than half have considered suicide in the last year, over 60% have reported self-harm in the last year, and more than 75% reported suffering symptoms of generalized anxiety disorder. [20] Based on what we know about the correlation between trauma, mental illness, and substance use, it is clear the reasons why illicit drug use is so high in these communities.
But drug use is also common in the trans and non-binary communities as a form of self-help and self-medication. Though inexplicably linked to trauma and mental illness, “self-medding” does not involve being diagnosed and defined by disorders that can feel constraining. A popular drug used within queer nightlife and trans culture is ketamine.
“Why wouldn’t you want to meet the day not wanting to die?”
Ketamine, “K”, or “ket” was developed in the 1960s and was used extensively during the Vietnam War for surgical anesthesia. [21] By the 1970s, researchers were studying its potential to treat addiction and bipolar disorder. By the ‘90s, ketamine had become a popular club drug, especially within queer nightlife where party drugs are abundant. In the last five years, the drug has exploded, both in recreational use but also as a legal form of psychedelic-assisted therapy. [22] In the psychiatric world, ketamine can be used to treat severe depression, and when combined with therapy, can allow patients to rework thought patterns and practice new behaviors while the brain is in a receptive state. This “receptive” state is really a dissociative state that allows users to step outside of their bodies and enjoy a “looseness” not found in everyday life. [23]
For folks struggling with gender dysphoria and not feeling at home in their bodies, this feeling is liberating. JP, a 34-year-old non-binary individual, who struggles with body dysmorphia, bulimia, and depression, tried ketamine at a music festival and
"The Ketamine Tiger"; portrait by Marisa Wood Bassett
described the feeling as if they could “actually face life.” [24] Unlike other party drugs, ketamine is not known for producing hangovers and negative after-effects; rather, users return to sobriety after using the drug feeling better and like “the dots have connected.” JP started using ketamine regularly as a type of antidepressant. They describe the positive effects:
“I remember one time looking in the mirror and feeling like I really saw myself for the first time,” they say.
“I cried and cried — there was so much acceptance. I was so far removed from my eating disorder and that negative voice that was there 24 hours a day.”
In her memoir trans girl suicide museum, writer Hannah Baer describes why ketamine is a drug reached for by the trans community, not only to help themselves, but to see others as they truly are: “Sometimes trans people’s gender presentations or experiences can have these different dissonant parts in them and k gives me the liberated compartmentalized eye to just see the ones they want me to see.” [25]
But rather than being used as simply a club drug or for experimentation, many trans and non-binary people have started using ketamine, and other psychedelics like mushrooms or LSD, regularly for self-medication. Author P.E. Moskowitz writes about the struggles they faced when seeking psychiatric help during their transition. After seeking help and being put on Wellbutrin, then Lexapro, then Effexor, Moskowitz felt detached from the world. They eventually started self-medicating by taking ketamine to “dissociate safely” and shrooms to “find forgiveness within myself.” Eventually, through on-and-off microdosing on LSD, Moskowitz felt restored: “Without exaggeration, that routine cured my depression.” [26]
Moskowitz’s experience, like JP’s, represents a trend in the trans and non-binary communities of people taking their healthcare into their own hands in a system often inaccessible to them. People from these marginalized communities have to struggle through the bureaucracy of a medical system that often doesn’t work for them or recognize what they need. This is on top of the financial inaccessibility – the U.S. easily places first internationally when looking at per-capita healthcare expenses, making it the most expensive system in the world for consumers. [27] Additionally, the medical system can be a hostile place. Moskowitz describes the difficulty of seeing so many doctors, and “the humiliation of having to convince medical authorities of [their] gender crisis.” Many insurance providers consider gender-affirming hormone therapy to be ‘elective.’ [28] And many trans and non-binary patients face discrimination at the doctor’s office – a 2015 Reuters report found that 42% of transgender respondents said they were faced with verbal or even physical abuse at a healthcare office or were denied equal treatment because of their gender identity. [29] Those that reported discrimination in the study were overwhelmingly “young, white, college-educated people with jobs and private health insurance,” [30] which begs the question of the level of abuse and discrimination that patients face who do not fit into these categories must experience. These factors illustrate the reasons why trans and nonbinary people may feel more comfortable procuring their own medications and therapies.
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Conclusion
So why is it important to study gender when it comes to drug use? Firstly, research is sparse on this topic – studies on addiction have preferred cisgender, heterosexual, white men for decades and this trend is only beginning to change. Second, a close look at gender socialization indicates that peoples’ experiences differ individually (why they use drugs, how long they continue, methods for using) and institutionally (how they are treated within the healthcare system and how successful rehabilitation is). Third, examining the effects of sex-based hormones demonstrate that those who produce estrogen are more vulnerable to the reinforcement mechanism of stimulant drugs like cocaine and methamphetamine, making their rehabilitation journey more difficult. Fourth, trauma and mental health issues are some of the highest risk-factors that predict SUD – women, transgender, and non-binary people are statistically more likely to face trauma and/or suffer from a mental health illness. Lastly, including transgender and non-binary folks in the conversation, in research studies, etc. is necessary because what limited knowledge the scientific community does have demonstrates that trans and non-binary people are at some of the highest risk for SUDs and are systematically unable to access the healthcare system. All of these factors play into how those suffering from a substance use disorder need adequate rehabilitation, which should be informed by gender to better help those struggling.
1. “Sex and Gender Differences in Substance Use,” National Institute on Drug Abuse, https://nida.nih.gov/publications/research-reports/substance-use-in-women/sex-gender-differences-in-substance-use.
2. “Risk Factors of Substance Use in Men,” High Focus Centers, last modified May 28, 2019, https://highfocuscenters.pyramidhealthcarepa.com/the-unique-risk-factors-of-substance-use-in-men/.
3. “A Study of Drug Addiction Between the Genders | Drug Abuse Vs. Addiction,” The Recovery Village Drug and Alcohol Rehab, https://www.therecoveryvillage.com/drug-addiction/study-between-genders/.
4. “Sex and Gender Differences in Substance Use.”
5. “Mother’s Little Helper: A Brief History of Benzodiazepines,” Mother’s Little Helper: A Brief History of Benzodiazepines, last modified March 17, 2015, https://mosaicscience.com/story/mothers-little-helper-brief-history-benzodiazepines.
6. Brecht M-L, O’Brien A, von Mayrhauser C, Anglin MD. Methamphetamine use behaviors and gender differences. Addict Behav. 2004;29(1):89-106.
7. Cretzmeyer M, Sarrazin MV, Huber DL, Block RI, Hall JA. Treatment of methamphetamine abuse: research findings and clinical directions. J Subst Abuse Treat. 2003;24(3):267-277.
8. National Institute on Drug Abuse, “Part 1: The Connection Between Substance Use Disorders and Mental Illness,” National Institute on Drug Abuse, 1, last modified --, https://nida.nih.gov/publications/research-reports/common-comorbidities-substance-use-disorders/part-1-connection-between-substance-use-disorders-mental-illness.
9. “A Study of Drug Addiction Between the Genders | Drug Abuse Vs. Addiction.”
10. Saurabh S. Kokane and Linda I. Perrotti, “Sex Differences and the Role of Estradiol in Mesolimbic Reward Circuits and Vulnerability to Cocaine and Opiate Addiction,” Frontiers in Behavioral Neuroscience 14 (May 20, 2020): 74.
11. “Women’s Hormones Play Role in Drug Addiction, Higher Relapse Rates: Attention Drawn to Lack of Female-Specific Research,” ScienceDaily, https://www.sciencedaily.com/releases/2019/02/190208161442.htm.
12. Matt Berry, “Why Women Are Underrepresented in Addiction Treatment,” American Addiction Centers, last modified April 13, 2021, https://americanaddictioncenters.org/blog/women-in-addiction-treatment.
13. “Women Underrepresented in Clinical Trials: Why That’s a Problem,” Healthline, last modified October 25, 2020, https://www.healthline.com/health-news/we-dont-have-enough-women-in-clinical-trials-why-thats-a-problem.
14. Jerome Hunt, “Why the Gay and Transgender Population Experiences Higher Rates of Substance Use,” Center for American Progress, March 9, 2012, https://www.americanprogress.org/article/why-the-gay-and-transgender-population-experiences-higher-rates-of-substance-use/.
15. Kelly E. Green and Brian A. Feinstein, “Substance Use in Lesbian, Gay, and Bisexual Populations: An Update on Empirical Research and Implications for Treatment.,” Psychology of Addictive Behaviors 26, no. 2 (June 2012): 265–278.
16. Jack K. Day et al., “Transgender Youth Substance Use Disparities: Results from a Population-Based Sample,” The Journal of adolescent health : official publication of the Society for Adolescent Medicine 61, no. 6 (December 2017): 729–735.
17. “Substance Abuse in the LGBTQ+ Community,” FHE Health – Addiction & Mental Health Care, last modified November 30, 2020, https://fherehab.com/news/lgbtq-substance-abuse/.
18. Kris Tunac De Pedro et al., “Substance Use Among Transgender Students in California Public Middle and High Schools,” Journal of School Health 87, no. 5 (2017): 303–309.
19. Jerome Hunt, “Why the Gay and Transgender Population Experiences Higher Rates of Substance Use.”
20. “Startling Mental Health Statistics among LGBTQ+ Are a Wake-up Call,” SAGE, August 31, 2020, https://www.sageusa.org/news-posts/startling-mental-health-statistics-among-lgbtq-are-a-wake-up-call/.
21. Edward F. Domino and David S. Warner, “Taming the Ketamine Tiger,” Anesthesiology 113, no. 3 (September 1, 2010): 678–684.
22. Twitter et al., “The Legal Psychedelic: Ketamine Is a Fast-Acting Treatment for Depression (If You Have the Money),” Los Angeles Times, last modified February 28, 2023, https://www.latimes.com/california/newsletter/2023-02-28/legal-psychedelic-ketamine-treatment-depression-if-you-have-the-money-group-therapy.
23. Ibid.
24. Delilah Friedler, “Does the Queer Scene Have a Ketamine Problem?,” Rolling Stone, January 6, 2023, https://www.rollingstone.com/culture/culture-features/ketamine-queer-scene-addiction-side-effects-1234656422/.
25. Noa/h Fields, “A Ketamine-Ramped Tour of the Trans Girl Suicide Museum,” ANMLY, May 13, 2020, https://medium.com/anomalyblog/a-ketamine-ramped-tour-of-the-trans-girl-suicide-museum-2961bc533efb.
26. Condé Nast, “Trans People Are Taking Mental Health Into Our Own Hands,” Them, last modified July 23, 2021, https://www.them.us/story/trans-people-mental-health-own-hands-microdosing-psychedelics-psychiatry.
27. “Infographic: The U.S. Has the Most Expensive Healthcare in the World,” Statista Infographics, last modified February 7, 2023, https://www.statista.com/chart/8658/health-spending-per-capita.
28. “Transgender and Addiction,” American Addiction Centers, https://americanaddictioncenters.org/lgbtqiapk-addiction/transgender.
29. “Transgender People Face Discrimination in Healthcare,” Reuters, March 13, 2015, sec. Healthcare & Pharma, https://www.reuters.com/article/us-transgender-healthcare-discrimination-idUSKBN0M928B20150313.
30. Ibid.